Improving patient safety by observing behavior

Tuesday, 5 March, 2013

A recent observational research study performed by Rydenfalt et al. explored the efficacy of the World Health Organization (WHO) Surgical Safety Checklist and the results of its proper usage. The WHO Surgical Safety Checklist is developed by professionals and, when applied as intended, can help increase patient safety. The checklist is based on a core set of safety standards. Read more on the WHO website.

The World Health Organization indicates that in recent years, countries have increasingly recognized the importance of improving patient safety, as it is a serious global public health issue, about which the WHO actively strives to improve public awareness and knowledge. Read 10 facts on patient safety here.

WHO checklist evaluation

Rydenfalt et al. (2013) evaluated the usage of the WHO checklist (version 1) that consists of three phases:
1) Sign in, before induction of anesthesia
2) Time out, before skin incision 
3) Sign out, before patient leaves operating room

Improving patient safety by observing behavior

They focused on the occurrence of checklist items in the Time out phase and identified several points for improvement. In order to analyze this phase quantitatively, Rydenfalt and colleagues recorded 24 surgical procedures using one camera in the operating room.

The team consisted of at least one surgeon, one nurse anesthetist, one theater nurse, and one assistant nurse. To accurately code behaviors, the researchers used The Observer XT software. They assessed whether participants engaged actively and coded the frequency in which items on the checklist occurred. Active participation was defined as: “a team member having some input either by asking or by answering questions on the checklist”. Checklist items were then coded as performed or not performed. An item such as verbal confirmation between Anesthesiologist/ nurse anesthetist, theater nurse, and surgeon regarding Patient ID was only coded as performed when there was an answer with the patient’s name or something comparable. Answers such as, “yes I know this patient” were not regarded as acceptable answers since there was no pertinent information shared with giving such an answer.

Naturalistic observation studies

Regarding the chosen method, Rydenfalt et al. explain “naturalistic observation studies can avoid the selective perception of participants and enable researchers to notice things that escape the awareness of the participants”. Furthermore, the researchers added qualitative data to their set by describing reasons for non-compliance. For example, they explain how the hospital personnel’s level of understanding regarding the intention of the checklist could influence its appropriate application (per item).

Although the results showed that the checklist was not always used as intended, the results also indicated that the Time out phase (step 2 in the checklist) was initiated in almost all surgical procedures. The study also showed that team members sometimes conducted other professional tasks, unrelated to the Time out, during the Time out phase, such as throwing out trash or raising the operating table. Moreover, the anesthesiologist, theater nurse, and surgeon only confirmed ‘site of incision’ in 25% of the occurrences (n=24). This could be the result of this information being perceived as irrelevant by the anesthesia team, explain Rydenfalt et al.

Communication in healthcare

One of the goals of the WHO checklist is to facilitate communication between team members. Because introductions can promote trust amongst team members and encourage team building, they are a part of the checklist that should not be overlooked. However, the study showed that team members did not always introduce themselves. Although it could be argued that team members already know each other from previous operations, this may not always be the case. When a stressful situation occurs, it may be too late to clarify names and roles of team members.  

Stressing the importance of underlying processes

Rydenfalt et al. explain that it is important to describe ‘risk’ as what can and should be done to avoid risks that expose patients to danger and thus improve patient safety. All personnel should be aware of the risk-reducing intention of the checklist. Additionally, risks are often linked to active failure, such as avoiding an incision in the healthy leg as opposed to the leg that requires surgery. However, risk can also be linked to communication failure. This second type of failure is not always considered to be a risk to patient safety. Therefore, Rydenfalt et al. state that communication failures and the checklist items related to facilitating good and clear communication may be perceived by hospital personnel as being less significant. Rydenfalt et al. conclude that adherence to the checklist will most likely involve altering the staff attitude towards checklist items, thereby facilitating effective risk-reducing communication. By addressing the importance of underlying processes, teamwork can be improved, thus positively influencing and increasing patient safety.


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  • Rydenfalt, C.; Johansson, G.; Odenrick, P.; Akerman, K.; Larsson, P.A. (2013). Compliance with the WHO surgical safety checklist: deviations and possible improvements. International Journal for Quality in Health Care, 1-6.
  • The World Health Organization